<p>Special Diet Accommodation Form</p><p>Have questions? Contact Seminole Dining Dietitian: Brittany Lord, RDN, LDN at [email protected]</p><p>Student Name: ______FSU Meal Plan: ______Student Phone Number: ______Emergency Contact Name: ______Student Email: ______EC Phone Number: ______</p><p>1. Student agrees for food allergy and/or other medical diagnosis to be shared with Seminole Dining staff? ___ Yes ___No May we also share your picture with dining staff? ___ Yes ___No </p><p>2. Indicate the length of time the special diet accommodations will be required. ___ Ongoing ___ Temporary: from ______until ______</p><p>3. Please complete the chart below.</p><p>“NO” Foods: (List any food allergies or intolerances) ______“Yes” Foods: (Safe and preferred foods) ______Preferred Default Meals: (Meals that can be prepared quickly and safely) Breakfast: ______Lunch: ______Dinner: ______</p><p>4. Other information you would like the Seminole Dining Dietitian to know? ______Please email the completed forms to [email protected]</p>